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1.
Ethn Dis ; 31(3): 433-444, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34295131

RESUMO

Introduction: The US Asian American (AA) population is projected to double by 2050, reaching ~43 million, and currently resides primarily in urban areas. Despite this, the geographic distribution of AA subgroup populations in US cities is not well-characterized, and social determinants of health (SDH) and health measures in places with significant AA/AA subgroup populations have not been described. Our research aimed to: 1) map the geographic distribution of AAs and AA subgroups at the city- and neighborhood- (census tract) level in 500 large US cities (population ≥66,000); 2) characterize SDH and health outcomes in places with significant AA or AA subgroup populations; and 3) compare SDH and health outcomes in places with significant AA or AA subgroup populations to SDH and health outcomes in places with significant non-Hispanic White (NHW) populations. Methods: Maps were generated using 2019 Census 5-year estimates. SDH and health outcome data were obtained from the City Health Dashboard, a free online data platform providing more than 35 measures of health and health drivers at the city and neighborhood level. T-tests compared SDH (unemployment, high-school completion, childhood poverty, income inequality, racial/ethnic segregation, racial/ethnic diversity, percent uninsured) and health outcomes (obesity, frequent mental distress, cardiovascular disease mortality, life expectancy) in cities/neighborhoods with significant AA/AA subgroup populations to SDH and health outcomes in cities/neighborhoods with significant NHW populations (significant was defined as top population proportion quintile). We analyzed AA subgroups including Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, and Other AA. Results: The count and proportion of AA/AA subgroup populations varied substantially across and within cities. When comparing cities with significant AA/AA subgroup populations vs NHW populations, there were few meaningful differences in SDH and health outcomes. However, when comparing neighborhoods within cities, areas with significant AA/AA subgroup vs NHW populations had less favorable SDH and health outcomes. Conclusion: When comparing places with significant AA vs NHW populations, city-level data obscured substantial variation in neighborhood-level SDH and health outcome measures. Our findings emphasize the dual importance of granular spatial and AA subgroup data in assessing the influence of SDH in AA populations.


Assuntos
Americanos Asiáticos , Determinantes Sociais da Saúde , Criança , Cidades , Humanos , Avaliação de Resultados em Cuidados de Saúde , Características de Residência
2.
Am J Prev Med ; 61(3): 394-401, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34108111

RESUMO

INTRODUCTION: Neighborhood walkability has been established as a potentially important determinant of various health outcomes that are distributed inequitably by race/ethnicity and sociodemographic status. The objective of this study is to assess the differences in walkability across major urban centers in the U.S. METHODS: City- and census tract-level differences in walkability were assessed in 2020 using the 2019 Walk Score across 500 large cities in the U.S. RESULTS: At both geographic levels, high-income and majority White geographic units had the lowest walkability overall. Walkability was lower with increasing tertile of median income among majority White, Latinx, and Asian American and Native Hawaiian and Pacific Islander neighborhoods. However, this association was reversed within majority Black neighborhoods, where tracts in lower-income tertiles had the lowest walkability. Associations varied substantially by region, with the strongest differences observed for cities located in the South. CONCLUSIONS: Differences in neighborhood walkability across 500 U.S. cities provide evidence that both geographic unit and region meaningfully influence associations between sociodemographic factors and walkability. Structural interventions to the built environment may improve equity in urban environments, particularly in lower-income majority Black neighborhoods.


Assuntos
Planejamento Ambiental , Características de Residência , Ambiente Construído , Cidades , Humanos , Caminhada
3.
Prev Chronic Dis ; 17: E137, 2020 11 05.
Artigo em Inglês | MEDLINE | ID: mdl-33155973

RESUMO

We evaluated whether using county-level data to characterize public health measures in cities biases the characterization of city populations. We compared 4 public health and sociodemographic measures in 447 US cities (percent of children living in poverty, percent of non-Hispanic Black population, age-adjusted cardiovascular disease mortality, life expectancy at birth) to the same measures calculated for counties that contain those cities. We found substantial and highly variable city-county differences within and across metrics, which suggests that use of county data to proxy city measures could hamper accurate allocation of public health resources and appreciation of the urgency of public health needs in specific locales.


Assuntos
Determinantes Sociais da Saúde/estatística & dados numéricos , População Urbana/estatística & dados numéricos , Afro-Americanos/estatística & dados numéricos , Doenças Cardiovasculares/mortalidade , Criança , Cidades , Feminino , Humanos , Expectativa de Vida , Masculino , Pobreza , Fatores de Risco , Estados Unidos/epidemiologia
4.
Front Public Health ; 8: 88, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32296672

RESUMO

As the Internal Revenue Service strengthens the public health focus of community benefit regulations, and many states do the same with their tax codes, hospitals are being asked to look beyond patients in their delivery system to understand and address the needs of geographic areas. With the opportunities this affords come challenges to be addressed. The regulations' focus on population health is not limited to a defined clinical population-and the resulting emphasis on upstream determinants of health and community engagement is unfamiliar territory for many healthcare systems. At the same time, for many community residents and community-based organizations, large medical institutions can feel complicated to engage with or unwelcoming. And for neighborhoods that have experienced chronic underinvestment in upstream determinants of health-such as social services, housing and education-funds made available by hospitals through their community health improvement activities may seem insufficient and unreliable. Despite these regulatory requirements, many hospitals, focused as they are on managing patients in their delivery system, have not yet invested significantly in community health improvement. Moreover, although there are important exceptions, community health improvement projects have often lacked a strong evidence base, and true health system-community collaborations are relatively uncommon. This article describes how a large academic medical center tapped into the expertise of its population health research faculty to partner with local community-based organizations to oversee the community health needs assessment and to design, implement and evaluate a set of geographically based community-engaged health improvement projects. The resulting program offers a paradigm for health system investment in area-wide population health improvement.


Assuntos
Saúde da População , Atenção à Saúde , Hospitais , Humanos , Saúde Pública , Serviço Social
5.
Am J Public Health ; 110(5): 689-692, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32191526

RESUMO

From April 2016 to June 2017, the Health + Housing Project employed four community health workers who engaged residents of two subsidized housing buildings in New York City to address individuals' broadly defined health needs, including social and economic risk factors. Following the intervention, we observed significant improvements in residents' food security, ability to pay rent, and connection to primary care. No immediate change was seen in acute health care use or more narrowly defined health outcomes.


Assuntos
Agentes Comunitários de Saúde/organização & administração , Promoção da Saúde/organização & administração , Pobreza/estatística & dados numéricos , Habitação Popular/normas , Abastecimento de Alimentos/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Cidade de Nova Iorque , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Fatores de Risco , Fatores Socioeconômicos
6.
JAMA Netw Open ; 2(4): e192200, 2019 04 05.
Artigo em Inglês | MEDLINE | ID: mdl-30977857

RESUMO

Importance: In response to rapidly growing interest in population health, academic medical centers are launching department-level initiatives that focus on this evolving discipline. This trend, with its potential to extend the scope of academic medicine, has not been well characterized. Objective: To describe the emergence of departments of population health at academic medical centers in the United States, including shared areas of focus, opportunities, and challenges. Design, Setting, and Participants: This qualitative study was based on a structured in-person convening of a working group of chairs of population health-oriented departments on November 13 and 14, 2017, complemented by a survey of core characteristics of these and additional departments identified through web-based review of US academic medical centers. United States medical school departments with the word population in their name were included. Centers, institutes, and schools were not included. Main Outcomes and Measures: Departments were characterized by year of origin, areas of focus, organizational structure, faculty size, teaching programs, and service engagement. Opportunities and challenges faced by these emerging departments were grouped thematically and described. Results: Eight of 9 population health-oriented departments in the working group were launched in the last 6 years. The 9 departments had 5 to 97 full-time faculty. Despite varied organizational structures, all addressed essential areas of focus spanning the missions of research, education, and service. Departments varied significantly in their relationships with the delivery of clinical care, but all engaged in practice-based and/or community collaboration. Common attributes include core attention to population health-oriented research methods across disciplines, emphasis on applied research in frontline settings, strong commitment to partnership, interest in engaging other sectors, and focus on improving health equity. Tensions included defining boundaries with other academic units with overlapping areas of focus, identifying sources of sustainable extramural funding, and facilitating the interface between research and health system operations. Conclusions and Relevance: Departments addressing population health are emerging rapidly in academic medical centers. In supporting this new framing, academic medicine affirms and strengthens its commitment to advancing population health and health equity, to improving the quality and effectiveness of care, and to upholding the social mission of medicine.


Assuntos
Centros Médicos Acadêmicos/tendências , Saúde da População , Faculdades de Medicina/tendências , Humanos , Pesquisa Qualitativa , Estados Unidos
7.
Am J Public Health ; 109(4): 585-592, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30789770

RESUMO

OBJECTIVES: To support efforts to improve urban population health, we created a City Health Dashboard with area-specific data on health status, determinants of health, and equity at city and subcity (census tract) levels. METHODS: We developed a Web-based resource that includes 37 metrics across 5 domains: social and economic factors, physical environment, health behaviors, health outcomes, and clinical care. For the largest 500 US cities, the Dashboard presents metrics calculated to the city level and, where possible, subcity level from multiple data sources, including national health surveys, vital statistics, federal administrative data, and state education data sets. RESULTS: Iterative input from city partners shaped Dashboard development, ensuring that measures can be compared across user-selected cities and linked to evidence-based policies to spur action. Reports from early deployment indicate that the Dashboard fills an important need for city- and subcity-level data, fostering more granular understanding of health and its drivers and supporting associated priority-setting. CONCLUSIONS: By providing accessible city-level data on health and its determinants, the City Health Dashboard complements local surveillance efforts and supports urban population health improvement on a national scale.


Assuntos
Comportamentos Relacionados com a Saúde , Equidade em Saúde , Determinantes Sociais da Saúde , Participação dos Interessados , Saúde da População Urbana/estatística & dados numéricos , Sistema de Vigilância de Fator de Risco Comportamental , Humanos
8.
Popul Health Manag ; 22(5): 385-393, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-30513070

RESUMO

In integrated health care systems, techniques that identify successes and opportunities for targeted improvement are needed. The authors propose a new method for estimating population health that provides a more accurate and dynamic assessment of performance and priority setting. Member data from a large integrated health system (n = 96,246, 73.8% female, mean age = 44 ± 0.01 years) were used to develop a mechanistic mathematical simulation, representing the top causes of US mortality in 2014 and their associated risk factors. An age- and sex-matched US cohort served as comparator group. The simulation was recalibrated and retested for validity employing the outcome measure of 5-year mortality. The authors sought to estimate potential population health that could be gained by improving health risk factors in the study population. Potential gains were assessed using both average life years (LY) gained and average quality-adjusted life years (QALYs) gained. The simulation validated well compared to integrated health system data, producing an AUC (area under the curve) of 0.88 for 5-year mortality. Current population health was estimated as a life expectancy of 84.7 years or 69.2 QALYs. Comparing potential health gain in the US cohort to the Kaiser Permanente cohort, eliminating physical inactivity, unhealthy diet, smoking, and uncontrolled diabetes resulted in an increase of 1.5 vs. 1.3 LY, 1.1 vs. 0.8 LY, 0.5 vs. 0.2 LY, and 0.5 vs. 0.5 LY on average per person, respectively. Using mathematical simulations may inform efforts by integrated health systems to target resources most effectively, and may facilitate goal setting.


Assuntos
Prestação Integrada de Cuidados de Saúde , Expectativa de Vida , Saúde da População , Anos de Vida Ajustados por Qualidade de Vida , Alocação de Recursos , Adulto , Idoso , Simulação por Computador , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Saúde da População/classificação , Fatores de Risco , Adulto Jovem
9.
Acad Med ; 94(6): 813-818, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30570494

RESUMO

The Triple Aim framework for advancing health care transformation elevated population health improvement as a central goal, together with improving patient experiences and reducing costs. Though population health improvement is often viewed in the context of clinical care delivery, broader-reaching approaches that bridge health care delivery, public health, and other sectors to foster area-wide health gains are gathering momentum. Academic medical centers (AMCs) across the United States are poised to play key roles in advancing population health and have begun to structure themselves accordingly. Yet, few frameworks exist to guide these efforts. Here, the authors offer a generalizable approach for AMCs to promote population health across the domains of research, education, and practice. In 2012, NYU School of Medicine, a major AMC dedicated to high-quality care of individual patients, launched an academic Department of Population Health with a strongly applied approach. A rigorous research agenda prioritizes scalable initiatives to improve health and reduce inequities in populations defined by race, ethnicity, geography, and/or other factors. Education targets population-level thinking among future physicians and research leadership among graduate trainees. Four key mission-bridging approaches offer a framework for population health departments in AMCs: engaging community, turning information into insight, transforming health care, and shaping policy. Challenges include tensions between research, practice, and evaluation; navigating funding sources; and sustaining an integrated, interdisciplinary approach. This framework of discipline-bridging, partnership-engaging inquiry, as it diffuses throughout academic medicine, holds great promise for realigning medicine and public health.


Assuntos
Centros Médicos Acadêmicos/organização & administração , Atenção à Saúde/métodos , Saúde da População/estatística & dados numéricos , Centros Médicos Acadêmicos/normas , Currículo , Reforma dos Serviços de Saúde/métodos , Humanos , Liderança , Modelos Educacionais , Saúde Pública/economia , Saúde Pública/normas , Faculdades de Medicina/legislação & jurisprudência , Estados Unidos/epidemiologia
10.
Subst Abus ; 39(4): 476-483, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29565782

RESUMO

BACKGROUND: We developed and implemented the Substance Abuse Research Education and Training (SARET) program for medical, dental, nursing, and social work students to address the dearth of health professionals pursuing research and careers in substance use disorders (SUD). SARET has 2 main components: (1) a novel online curriculum addressing core SUD research topics, to reach a large number of students; (2) a mentored summer research experience for in-depth exposure. METHODS: Modules were integrated into the curricula of the lead institution, and of 5 external schools. We assessed the number of Web modules completed and their effect on students' interest in SUD research. We also assessed the impact of the mentorship experience on participants' attitudes and early career trajectories, including current involvement in SUD research. RESULTS: Since 2008, over 24,000 modules have been completed by approximately 9700 individuals. In addition to integration of the modules into curricula at the lead institution, all 5 health-professional partner schools integrated at least 1 module and approximately 5500 modules were completed by individuals outside the lead institution. We found an increase in interest in SUD research after completion of the modules for students in all 4 disciplines. From 2008 to 2015, 76 students completed summer mentorships; 8 students completed year-long mentorships; 13 published in SUD-related journals, 18 presented at national conferences, and 3 are actively engaged in SUD-related research. Mentorship participants reported a positive influence on their attitudes towards SUD-related clinical care, research, and interprofessional collaboration, leading in some cases to changes in career plans. CONCLUSIONS: A modular curriculum that stimulates clinical and research interest in SUD can be successfully integrated into medical, dental, nursing, and social work curricula. The SARET program of mentored research participation fostered early research successes and influenced career choice of some participants. Longer-term follow-up will enable us to assess more distal careers of the program.


Assuntos
Pesquisa Comportamental/educação , Escolha da Profissão , Educação/estatística & dados numéricos , Ocupações em Saúde/educação , Avaliação de Programas e Projetos de Saúde , Transtornos Relacionados ao Uso de Substâncias , Pesquisa Comportamental/tendências , Currículo , Educação/métodos , Educação/tendências , Conhecimentos, Atitudes e Prática em Saúde , Ocupações em Saúde/estatística & dados numéricos , Humanos , Internet , Tutoria
11.
J Addict Med ; 11(5): 333-338, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28590393

RESUMO

: The presence of structured addiction research training programs helps to ensure that the scientific workforce includes well-trained, diverse scientists necessary to reduce the negative impact of alcohol, drug, and tobacco use disorders. Although the field has made significant progress in the development of standards for clinical training in addiction medicine, there remains significant room for improvement in the training of addiction researchers, and also opportunities to synergize across addiction research training programs. The purpose of this commentary is to describe 4 National Institutes of Health (NIH)-sponsored addiction research training programs, highlight critical components, and provide recommendations for more comprehensive and effective program evaluation. Moving forward, evaluation of addiction research training programs would be enhanced by the use of conceptual models to inform process and outcome evaluations, the application of innovative methods to ensure long-term data collection, the improvement of mentorship evaluation measures, and the integration of training methods from other fields of study. We encourage NIH and others in the field to be proactive in establishing core metrics for evaluation across programs. Furthermore, centralized tracking of NIH-funded addiction research trainees, analysis of aggregate data across programs, and innovative methods to effectively disseminate program materials and processes are recommended.


Assuntos
Comportamento Aditivo , Pesquisa Biomédica , National Institutes of Health (U.S.) , Desenvolvimento de Programas , Pesquisa Biomédica/educação , Humanos , Estados Unidos
12.
Addict Sci Clin Pract ; 12(1): 7, 2017 02 28.
Artigo em Inglês | MEDLINE | ID: mdl-28245872

RESUMO

BACKGROUND: Buprenorphine maintenance for opioid dependence remains of limited availability among underserved populations, despite increases in US opioid misuse and overdose deaths. Low threshold primary care treatment models including the use of unobserved, "home," buprenorphine induction may simplify initiation of care and improve access. Unobserved induction and long-term treatment outcomes have not been reported recently among large, naturalistic cohorts treated in low threshold safety net primary care settings. METHODS: This prospective clinical registry cohort design estimated rates of induction-related adverse events, treatment retention, and urine opioid results for opioid dependent adults offered buprenorphine maintenance in a New York City public hospital primary care office-based practice from 2006 to 2013. This clinic relied on typical ambulatory care individual provider-patient visits, prescribed unobserved induction exclusively, saw patients no more than weekly, and did not require additional psychosocial treatment. Unobserved induction consisted of an in-person screening and diagnostic visit followed by a 1-week buprenorphine written prescription, with pamphlet, and telephone support. Primary outcomes analyzed were rates of induction-related adverse events (AE), week 1 drop-out, and long-term treatment retention. Factors associated with treatment retention were examined using a Cox proportional hazard model among inductions and all patients. Secondary outcomes included overall clinic retention, buprenorphine dosages, and urine sample results. RESULTS: Of the 485 total patients in our registry, 306 were inducted, and 179 were transfers already on buprenorphine. Post-induction (n = 306), week 1 drop-out was 17%. Rates of any induction-related AE were 12%; serious adverse events, 0%; precipitated withdrawal, 3%; prolonged withdrawal, 4%. Treatment retention was a median 38 weeks (range 0-320) for inductions, compared to 110 (0-354) weeks for transfers and 57 for the entire clinic population. Older age, later years of first clinic visit (vs. 2006-2007), and baseline heroin abstinence were associated with increased treatment retention overall. CONCLUSIONS: Unobserved "home" buprenorphine induction in a public sector primary care setting appeared a feasible and safe clinical practice. Post-induction treatment retention of a median 38 weeks was in line with previous naturalistic studies of real-world office-based opioid treatment. Low threshold treatment protocols, as compared to national guidelines, may compliment recently increased prescriber patient limits and expand access to buprenorphine among public sector opioid use disorder patients.


Assuntos
Buprenorfina/administração & dosagem , Antagonistas de Entorpecentes/administração & dosagem , Visita a Consultório Médico/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Atenção Primária à Saúde , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , New York , Estados Unidos
13.
Subst Abus ; 38(2): 150-156, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28328306

RESUMO

BACKGROUND: The Substance Abuse Research and Education Training (SARET) program is funded by the National Institutes of Drug Abuse in 2006 as a novel approach to spark interest in substance abuse research among medical, dental, nursing, and social work graduate students through a Web-based curriculum and research mentorships. This report presents the initial integration of the intervention in a Master of Social Work (MSW) program, the components of the program, and the mixed-methods evaluation of its effect on students' attitudes towards substance abuse research and treatment. METHODS: SARET comprises 2 main components: stipend-supported research mentorships and a Web-based module series, consisting of 6 interactive, multimedia modules addressing core SA research topics, delivered via course curricula and in the research mentorships. An initial evaluation was designed to assess SARET's acceptability and short-term impact on participants' interest in SA research. The components of this Web-based curriculum evaluation include focus group feedback on the relevance of the modules to SW students, number of courses into which the modules were integrated with number of module completions, changes in interest in SA research associated with module completion. RESULTS: The full series of Web-based modules has been integrated across several courses in the social work curriculum, and social work students have become integral participants in the summer mentored research experience. One hundred eighteen students completed at least 1 module and 42 students completed all 6 modules. Neurobiology, Screening, and Epidemiology were the most widely viewed modules. Students reported positive impact on their vision of SA-related clinical care, more positive attitudes about conducting research, and in some cases, change in career. CONCLUSIONS: The SARET program's modules and summer mentored research increased clinical and research interest related to SUDs, as well as interprofessional attitudes among social work students. Participants have shown some early research success. Longer-term follow-up will enable us to continue to assess the effectiveness of the program.


Assuntos
Educação de Pós-Graduação em Medicina , Desenvolvimento de Programas , Avaliação de Programas e Projetos de Saúde , Pesquisa/educação , Serviço Social/educação , Transtornos Relacionados ao Uso de Substâncias , Currículo , Feminino , Grupos Focais , Humanos , Masculino
14.
J Interprof Educ Pract ; 9: 99-103, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29359199

RESUMO

The NIDA funded Substance Abuse Education, Research and Training (SARET) Program addresses the compelling need for health professionals prepared to engage in substance use disorders (SUD) research. The goal of this interprofessional project, structured by an Executive Committee of co-investigators from the disciplines of medicine, nursing, social work and dentistry, is to increase the skills of students from each discipline for interprofessional research collaboration and early career-development opportunities in SUD research. The development of web-based modules, interprofessional seminars and a model mentorship program were designed as well, for dissemination and evaluation by other health professional schools. The educational format is 6 interactive web-based learning modules, providing an overview of core content on Substance Use Disorders (SUD), summer or year-long mentored research experiences with NIH-funded researchers and small interprofessional seminars and site visits. Assessment consists of self-reported annual student learning outcomes and external editorial and advisory board project and curricular materials review. These reviews encourages the updating of materials and provide flexibility for participating "champions" at other schools who use the modules. Quantitative and qualitative outcomes of student research activities and data on dissemination of modules support the fit between project content and interprofessional teaching modalities. The learning modules are available without charge to individuals, students, faculty or health professional programs from the project's website.

16.
Drug Alcohol Depend ; 165: 38-44, 2016 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-27344194

RESUMO

BACKGROUND: An Audio Computer-assisted Self Interview (ACASI) version of the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) could reduce barriers to substance use screening and assessment in primary care settings. This study evaluated the diagnostic accuracy of an ACASI ASSIST for identification of unhealthy substance use and substance use disorders (SUD). METHODS: 399 adult patients were consecutively recruited from an urban safety-net primary care clinic. ACASI ASSIST scores for tobacco, alcohol, marijuana, and cocaine were compared against reference standard measures to assess the instrument's diagnostic accuracy for identifying unhealthy use and SUD, first using empirically-derived optimal cutoffs, and second using the currently recommended ASSIST cutoffs. RESULTS: For identifying any unhealthy use, at the empirically-derived cutoffs the ACASI ASSIST had 93.6% sensitivity and 85.8% specificity (AUC=0.90) for tobacco, 85.9% sensitivity and 60.3% specificity (AUC=0.73), for alcohol in men, 100% sensitivity and 62.4% specificity (AUC=0.81) for alcohol in women, 94.6% sensitivity and 81.6% specificity (AUC=0.88) for marijuana, and 86.1% sensitivity, 84.0% specificity (AUC=0.85) for cocaine. For SUD, sensitivity ranged from 79% (for alcohol in males), to 100% (for tobacco), and specificity was 83% or higher (AUCs ranged 0.83-0.91). For substances other than tobacco, empirically-derived cutoff scores were lower than the standard cutoffs, and resulted in higher sensitivity and lower specificity for identifying unhealthy substance use. CONCLUSIONS: The ACASI ASSIST is a valid measure of unhealthy use and SUD for substances that are commonly used by primary care patients, and could facilitate effective and efficient screening for substance use in medical settings.


Assuntos
Atenção Primária à Saúde/métodos , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Adolescente , Adulto , Idoso , Confiabilidade dos Dados , Diagnóstico por Computador/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Autorrelato , Sensibilidade e Especificidade , Inquéritos e Questionários , Adulto Jovem
17.
Contemp Clin Trials ; 49: 57-64, 2016 07.
Artigo em Inglês | MEDLINE | ID: mdl-27178765

RESUMO

BACKGROUND: Extended-release naltrexone (XR-NTX) is an injectable monthly sustained-release mu opioid receptor antagonist, which blocks the typical effects of heroin and other opioid agonists. Use of XR-NTX among opioid dependent persons leaving jails and prisons is increasing despite scant high-quality evidence regarding XR-NTX's effectiveness at re-entry. METHODS: This 24-week, open-label randomized controlled trial examines the effectiveness of XR-NTX as opioid relapse prevention at release from jail (N=85) compared to enhanced treatment as usual (ETAU, N=85). A third, non-randomized, quasi-experimental naturalistic arm of participants who have newly initiated a jail-to-community methadone treatment program (MTP, N=85) allows for comparisons to a methadone standard-of-care. RESULTS: We describe the rationale, design, and primary and secondary outcomes of the study. The primary outcome is an opioid relapse event; the primary contrast is a time-to-relapse comparison of XR-NTX and ETAU over a 24-week treatment phase. Secondary outcomes are rates of: (a) post-release opioid treatment participation, (b) opioid, alcohol, and cocaine use, (c) injection drug use and HIV sexual risk behaviors, (d) overdose (fatal and non-fatal) and all-cause mortality, and, (e) re-incarceration. CONCLUSIONS: XR-NTX is a potentially important, effective treatment and relapse prevention option for a large US population of persons with opioid use disorders leaving jails. This study will estimate XR-NTX's effectiveness relative to existing standards of care, including counseling-only treatment-as-usual and methadone maintenance.


Assuntos
Naltrexona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Prisões , Analgésicos Opioides/uso terapêutico , Causas de Morte , Preparações de Ação Retardada , Overdose de Drogas/prevenção & controle , Humanos , Injeções Intramusculares , Metadona/uso terapêutico , Mortalidade , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/reabilitação , Participação do Paciente , Prevenção Secundária
18.
N Engl J Med ; 374(13): 1232-42, 2016 Mar 31.
Artigo em Inglês | MEDLINE | ID: mdl-27028913

RESUMO

BACKGROUND: Extended-release naltrexone, a sustained-release monthly injectable formulation of the full mu-opioid receptor antagonist, is effective for the prevention of relapse to opioid dependence. Data supporting its effectiveness in U.S. criminal justice populations are limited. METHODS: In this five-site, open-label, randomized trial, we compared a 24-week course of extended-release naltrexone (Vivitrol) with usual treatment, consisting of brief counseling and referrals for community treatment programs, for the prevention of opioid relapse among adult criminal justice offenders (i.e., persons involved in the U.S. criminal justice system) who had a history of opioid dependence and a preference for opioid-free rather than opioid maintenance treatments and who were abstinent from opioids at the time of randomization. The primary outcome was the time to an opioid-relapse event, which was defined as 10 or more days of opioid use in a 28-day period as assessed by self-report or by testing of urine samples obtained every 2 weeks; a positive or missing sample was computed as 5 days of opioid use. Post-treatment follow-up occurred at weeks 27, 52, and 78. RESULTS: A total of 153 participants were assigned to extended-release naltrexone and 155 to usual treatment. During the 24-week treatment phase, participants assigned to extended-release naltrexone had a longer median time to relapse than did those assigned to usual treatment (10.5 vs. 5.0 weeks, P<0.001; hazard ratio, 0.49; 95% confidence interval [CI], 0.36 to 0.68), a lower rate of relapse (43% vs. 64% of participants, P<0.001; odds ratio, 0.43; 95% CI, 0.28 to 0.65), and a higher rate of opioid-negative urine samples (74% vs. 56%, P<0.001; odds ratio, 2.30; 95% CI, 1.48 to 3.54). At week 78 (approximately 1 year after the end of the treatment phase), rates of opioid-negative urine samples were equal (46% in each group, P=0.91). The rates of other prespecified secondary outcome measures--self-reported cocaine, alcohol, and intravenous drug use, unsafe sex, and reincarceration--were not significantly lower with extended-release naltrexone than with usual treatment. Over the total 78 weeks observed, there were no overdose events in the extended-release naltrexone group and seven in the usual-treatment group (P=0.02). CONCLUSIONS: In this trial involving criminal justice offenders, extended-release naltrexone was associated with a rate of opioid relapse that was lower than that with usual treatment. Opioid-use prevention effects waned after treatment discontinuation. (Funded by the National Institute on Drug Abuse; ClinicalTrials.gov number, NCT00781898.).


Assuntos
Criminosos , Naltrexona/administração & dosagem , Antagonistas de Entorpecentes/administração & dosagem , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Adulto , Serviços de Saúde Comunitária , Aconselhamento , Preparações de Ação Retardada , Overdose de Drogas , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Naltrexona/efeitos adversos , Antagonistas de Entorpecentes/efeitos adversos , Transtornos Relacionados ao Uso de Opioides/complicações , Transtornos Relacionados ao Uso de Opioides/terapia , Prevenção Secundária , Abuso de Substâncias por Via Intravenosa/complicações
19.
Addiction ; 111(2): 233-44, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26360315

RESUMO

BACKGROUND AND AIMS: To address barriers to implementing the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in medical settings, we adapted the traditional interviewer-administered (IA) ASSIST to an audio-guided computer assisted self-interview (ACASI) format. This study sought to validate the ACASI ASSIST by estimating the concordance, correlation and agreement of scores generated using the ACASI versus the reference standard IA ASSIST. Secondary aims were to assess feasibility and compare ASSIST self-report to drug testing results. DESIGN: Participants completed the ACASI and IA ASSIST in a randomly assigned order, followed by drug testing. SETTING: Urban safety-net primary care clinic in New York City, USA. PARTICIPANTS: A total of 393 adult patients. MEASUREMENTS: Scores generated by the ACASI and IA ASSIST; drug testing results from saliva and hair samples. FINDINGS: Concordance between the ACASI and IA ASSIST in identifying moderate-high-risk use was 92-99% for each substance class. Correlation was excellent for global scores [intraclass correlation (ICC) = 0.937, confidence interval (CI) = 0.924-0.948] and for substance-specific scores for tobacco (ICC = 0.927, CI = 0.912-0.940), alcohol (ICC = 0.912, CI = 0.893-0.927) and illicit drugs (ICC = 0.854, CI = 0.854-0.900) and good for prescription drugs (ICC = 0.676, CI = 0.613-0.729). Ninety-four per cent of differences in global scores fell within anticipated limits of agreement. Among participants with a positive saliva test, 74% self-reported use on the ACASI ASSIST. The ACASI ASSIST required a median time of 3.7 minutes (range 0.7-15.4), and 21 (5.3%) participants requested assistance. CONCLUSIONS: The computer self-administered Alcohol, Smoking and Substance Involvement Screening Test appears to be a valid alternative to the interviewer-administered approach for identifying substance use in primary care patients.


Assuntos
Consumo de Bebidas Alcoólicas , Autorrelato/normas , Fumar , Detecção do Abuso de Substâncias/métodos , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Adulto , Idoso , Computadores , Diagnóstico por Computador/normas , Diagnóstico Precoce , Feminino , Humanos , Entrevistas como Assunto/normas , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque , Atenção Primária à Saúde , Medição de Risco , Inquéritos e Questionários/normas , Adulto Jovem
20.
J Gen Intern Med ; 30(11): 1657-64, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-25947881

RESUMO

BACKGROUND: Hospital care on weekends has been associated with delays in care, reduced quality, and poor clinical outcomes. OBJECTIVE: The purpose of this study was to evaluate the impact of a weekend hospital intervention on processes of care and clinical outcomes. The multifaceted intervention included expanded weekend diagnostic services, improved weekend discharge processes, and increased physician and care management services on weekends. DESIGN AND PATIENTS: This was an interrupted time series observational study of adult non-obstetric patients hospitalized at a single academic medical center between January 2011 and January 2014. The study included 18 months prior to and 19 months following the implementation of the intervention. Data were analyzed using segmented regression analysis with adjustment for confounders. MAIN MEASURES: The primary outcome was average length of stay. Secondary outcomes included percent of patients discharged on weekends, 30-day readmission rate, and in-hospital mortality rate. KEY RESULTS: The study included 57,163 hospitalizations. Following implementation of the intervention, average length of stay decreased by 13 % (95 % CI 10-15 %) and continued to decrease by 1 % (95 % CI 1-2 %) per month as compared to the underlying time trend. The proportion of weekend discharges increased by 12 % (95 % CI 2-22 %) at the time of the intervention and continued to increase by 2 % (95 % CI 1-3 %) per month thereafter. The intervention had no impact on readmissions or mortality. During the post-implementation period, the hospital was evacuated and closed for 2 months due to damage from Hurricane Sandy, and a new hospital-wide electronic health record was introduced. The contributions of these events to our findings are not known. We observed a lower inpatient census and found differences in patient characteristics, including higher rates of Medicaid insurance and comorbidities, in the post-Hurricane Sandy period as compared to the pre-Sandy period. CONCLUSIONS: The intervention was associated with a reduction in length of stay and an increase in weekend discharges. Our longitudinal study also illuminated the challenges of evaluating the effectiveness of a large-scale intervention in a real-world hospital setting.


Assuntos
Centros Médicos Acadêmicos/organização & administração , Plantão Médico/organização & administração , Melhoria de Qualidade/organização & administração , Centros Médicos Acadêmicos/normas , Adulto , Plantão Médico/normas , Idoso , Idoso de 80 Anos ou mais , Registros Eletrônicos de Saúde/estatística & dados numéricos , Registros Eletrônicos de Saúde/tendências , Feminino , Pesquisa sobre Serviços de Saúde/métodos , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , New York , Alta do Paciente/estatística & dados numéricos , Alta do Paciente/tendências , Readmissão do Paciente/estatística & dados numéricos , Fatores de Tempo
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